BENEFICIARY DESIGNATION - DOC by A343R5

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									 TEMPLE UNIVERSITY
  Human Resources



                                    Change of Beneficiary Form

Please complete the following information (PLEASE PRINT OR TYPE):


Name:                                                                           TUID:

    Group Term Life Insurance                       Accidental Death and Dismemberment

Effective date of change:

I designate the beneficiary/beneficiaries shown below to receive all sums due on account of my death under the
Group Term Life Insurance policy and/or Accidental Death and Dismemberment policy provided by Temple
University (Please note: you must select at least one primary designation. If you designate more than one
primary beneficiary, all sums due will be divided equally among surviving primary beneficiaries unless
otherwise specified below):

                             Name                                                     Relationship

Primary designation:




Contingent designation:




Signature                                                                          Date Signed


Forms should be scanned and emailed to benefits@temple.edu, faxed to 215-204-9336, or returned to:

        Mailing Address:                                       Physical Address:
        Temple University Human Resources                      Temple University Human Resources
        Benefits Department                                    Benefits Department
        TASB (083-39)                                          1st Floor
        1852 N. 10th Street                                    2450 W Hunting Park Avenue
        Philadelphia, PA 19122                                 Philadelphia, PA 19129

								
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